No small achieve­ment

Ru­ral providers show size isn’t bar­rier to IT suc­cess

Modern Healthcare - - INFORMATION TECHNOLOGY - Joseph Conn

Some small, ru­ral health­care or­ga­ni­za­tions have be­come health in­for­ma­tion tech­nol­ogy front-run­ners and their lead­ers techno mavens, de­spite the dig­i­tal di­vide that sep­a­rates the larger, ur­ban health IT have-nows from the smaller, ru­ral IT have-not-yets.

Four ru­ral providers show how it can be done. Two each from West Vir­ginia and Louisiana were iden­ti­fied by health IT of­fi­cials in their states for their pluck in cross­ing the di­vide, demon­strat­ing that size and ge­og­ra­phy need not cre­ate in­sur­mount­able bar­ri­ers. All have qual­i­fied for fed­eral EHR in­cen­tive pay­ments, ei­ther as an el­i­gi­ble or­ga­ni­za­tion or by their mem­ber physi­cians, un­der the Amer­i­can Re­cov­ery and Rein­vest­ment Act. They’ve joined health in­for­ma­tion ex­changes and used data from their sys­tems to ad­vance pub­lic health and di­rect pa­tient care. Com­mon traits th­ese or­ga­ni­za­tions and their lead­ers ex­hibit are col­lab­o­ra­tion, de­ter­mi­na­tion, faith and savvy grant-writ­ing.

Ru­ral by na­ture

Few states are more coun­try than West Vir­ginia, where 51% of its peo­ple live in ru­ral ar­eas. (Only Maine and Ver­mont have higher per­cent­ages.)

In 2000, 20 of the state’s com­mu­nity health cen­ters banded to­gether as the Com­mu­nity Health Net­work of West Vir­ginia, in part to cre­ate economies of scale for health­care IT projects. The net­work first of­fered a re­mote-hosted prac­tice man­age­ment sys­tem, then, in 2008, through a pilot pro­gram funded by the Health Re­sources and Ser­vices Ad­min­is­tra­tion, it added an elec­tronic health record, the Re­source and Pa­tient Man­age­ment Sys­tem de­vel­oped by the In­dian Health Ser­vice from the Vet­er­ans Af­fairs Depart­ment’s VistA EHR.

“We re­ally wanted to do pop­u­la­tion health,” says David Camp­bell, the net­work’s CEO. “We knew that’s where health­care was go­ing, and in our ru­ral com­mu­ni­ties we had to look at a very di­verse pop­u­la­tion. We wanted a pub­lic util­ity that you could plug into with a sub­scrip­tion model. For what we were try­ing to ac­com­plish at the time, RPMS was the best sys­tem avail­able.”

One net­work EHR user is Pendle­ton Com­mu­nity Care in Franklin, pop­u­la­tion 720. Pendle­ton County, on the eastern edge of the Al­leghe­nies, is hemmed in by four ma­jor moun­tains and “lots of hollers, as we call them,” says na­tive West Vir­ginian Michael Judy, the clinic’s CEO. The only other health­care provider in the county of about 7,700 res­i­dents is an of­fice staffed by a part-time physi­cian as­sis­tant.

The clinic is staffed by three fam­ily prac­ti­tion­ers, a pe­di­a­tri­cian, three physi­cian as­sis­tants and a nurse prac­ti­tioner. It has a satel­lite of­fice else­where in the county. Com­ing soon is a preven­tive, pri­mary-care pro­gram in four pub­lic schools. Its clin­i­cians han­dle 18,000 pa­tient en­coun­ters a year, in­clud­ing those from about 300 vet­er­ans, whom the clinic treats un­der a con­tract with the Vet­er­ans Af­fairs Depart­ment.

RPMS is piped to the clinic from the Com­mu­nity Health Net­work’s data cen­ter in Bar­boursville, 240 miles away. VistA is fed to the clinic, too, from a VA hos­pi­tal in Martins­burg, 133 miles north.

Dr. Laura Nulph, a fam­ily physi­cian at the clinic since 2008, leads its qual­ity-im­prove­ment com­mit­tee, us­ing RPMS to gather and per­form data anal­y­sis on a host of mea­sures, a task that would have been so la­bor-in­ten­sive as to have been al­most im­pos­si­ble with pa­per records.

Over the past year, clin­i­cians have in­creased the per­cent­age of pa­tients get­ting Pap tests from 42% to 47%; col­orec­tal can­cer tests from 42% to 48%; di­a­betic eye ex­ams from 39% to 49%; and di­a­betic foot ex­ams from 52% to 57%.

“We’re see­ing small gains, but it’s bet­ter than stand­ing still or go­ing back­wards,” Nulph says.

Tar­get­ing pa­tients

In the cen­tral West Vir­ginia vil­lage of Clay, with a pop­u­la­tion of about 490, Dr. Sarah Chouinard heads Com­mu­nity Care of West Vir­ginia, also a Com­mu­nity Health Net­work mem­ber. With nine clin­ics, six pharmacies, a den­tal clinic and mul­ti­ple school-based clin­ics, it serves pa­tients in nine coun­ties, han­dling about 100,000 en­coun­ters a year.

Com­mu­nity Care, an early RPMS user, switched to a Web-based EHR and prac­tice-man­age­ment sys­tem from Athenahealth in Oc­to­ber, al­though start­ing with the In­dian

Health Ser­vice’s EHR was “one of the best learn­ing ex­pe­ri­ences we could have had,” Chouinard says.

“We learned how to prac­tice medicine in a med­i­cal home,” she says. “What you re­ally have to do is data an­a­lyt­ics—of all my pa­tients, X are women, and what per­cent­age is due for mam­mo­grams?” RPMS ex­cels at that sort of pop­u­la­tion man­age­ment re­port­ing.

Chouinard says the new sys­tem is tak­ing the clinic net­work to the next tech­no­log­i­cal level. More than half of the clinic’s pa­tients have signed up to use its pa­tient por­tal, for ex­am­ple.

The tech­nol­ogy is also help­ing the net­work tar­get spe­cific pa­tient pop­u­la­tions. Bon­nie’s Bus is a mo­bile, dig­i­tal breast can­cer screen­ing ser­vice run by West Vir­ginia Univer­sity, but uti­liza­tion of the ser­vice by Com­mu­nity Care pa­tients had been low. The clinic would dis­trib­ute fliers be­fore its vis­its, Chouinard says, but with its EHR and prac­tice-man­age­ment sys­tems now fully in­te­grated, the clin­ics can iden­tify pa­tients both in need of a mam­mo­gram and with­out health in­sur­ance cov­er­age who’d ben­e­fit most from the free ser­vice. “Now, we can call up and say, ‘Sandy, don’t miss this op­por­tu­nity.’ So, it’s just bet­ter care co­or­di­na­tion.”

Stormy start

Sta­tis­ti­cally speak­ing, Louisiana is con­sid­er­ably less ru­ral than West Vir­ginia. About 27% of its peo­ple live in ru­ral ar­eas, but it has other chal­lenges.

“The IT push for us all got started af­ter hur­ri­canes Ka­t­rina and Rita,” says Linda Deville, CEO of Bunkie (La.) Gen­eral Hos­pi­tal, an 18bed crit­i­cal-ac­cess hos­pi­tal with an eight-bed psy­chi­atric unit. Refugees from New Or­leans and Ba­ton Rouge fled north and west from Ka­t­rina in Au­gust 2005, and north and east from Lake Charles from Rita a month later. The hu­man waves of pa­tients with­out med­i­cal records crashed on Bunkie, a town of about 4,100 peo­ple.

“We’re in cen­tral Louisiana, so we were the first stop,” Deville says.

The one-two punch of Ka­t­rina and Rita raised health IT con­scious­ness all along the Gulf Coast. The Louisiana Leg­is­la­ture al­lo­cated $15 mil­lion to start a health in­for­ma­tion ex­change and of­fered $1 mil­lion grants to the first seven health­care or­ga­ni­za­tions to pur­chase health in­for­ma­tion tech­nol­ogy, Deville re­calls.

Bunkie won a grant, and then rushed to get its new EHR up and run­ning by the state dead­line. The in­stal­la­tion started in Jan­uary 2008 and “had to be sub­stan­tially com­plete by June 30, when state fund­ing ended,” Deville says. The think­ing was, “We may never have an­other $1 mil­lion to do this. It was rip the Band-Aid off. We were the first crit­i­cal-ac­cess hos­pi­tal (in Louisiana) to go fully elec­tronic.”

Bunkie also was the first of the state’s 29 CAHs to join the in­for­ma­tion ex­change, run by the Louisiana Health Care Qual­ity Fo­rum, based in Ba­ton Rogue. The link went live in Septem­ber 2012. So far, 130 Louisiana hos­pi­tals, 35 in ru­ral ar­eas, in­clud­ing 20 CAHs, are con­nected to the in­for­ma­tion ex­change, says spokes­woman Linda Mor­gan.

“It’s just the very be­gin­ning of this, so there’s not a whole lot of health­care in­for­ma­tion in the net­work as we speak,” Deville says. Bunkie also re­cently launched a clin­i­cal and psy­chi­atric tele­health pro­gram in con­junc­tion with the LSU Health Sciences Cen­ter in Shreve­port. The pro­gram loads a num­ber of tele­health tools on a rolling cart.

“We call it our com­puter on wheels,” she says. Aboard the cart are a stetho­scope, skin cam­era and other tools. “They have a doc­tor in Shreve­port and you talk to him. The doc­tor has a head­set and a nurse (at the clinic) has a head­set. He can hear the heart­beat in real time and tell the nurse to move it left and right. The skin cam­era can take snap­shots and put it in the elec­tronic health record and mag­nify it.”

In calmer times, the hos­pi­tal and its two out­pa­tient clin­ics draw nearly 20,000 pa­tients. “It is harder for a small hos­pi­tal,” Deville says, but on the other hand, “you don’t have all the pol­i­tics. It’s ‘this is what we have, let’s work with it.’ ”

Track­ing the data

In the small, cen­tral Louisiana city of Win­n­field, with a pop­u­la­tion of about 4,840, folks still call Deano Thorn­ton “mayor.”

“That’s one of the nicer things you get called at times,” says Thorn­ton, now CEO of Winn Com­mu­nity Health Cen­ter, a fed­er­ally qual­i­fied health­care cen­ter. “I had 27 years in mu­nic­i­pal govern­ment, 16 years as mayor.”

Thorn­ton says he rec­og­nized the need for af­ford­able, ac­ces­si­ble care by lis­ten­ing to his con­stituents. “We own our own elec­tri­cal sys­tem, and peo­ple had to make a choice to pay the light bill or pay for medicine,” he says “‘I couldn’t pay the light bill be­cause my son was sick.’ I heard it ev­ery week.”

The cen­ter opened in 2009 with fund­ing from the Rapi­des Foun­da­tion, Alexan­dria, La. It had a Web-based EHR sys­tem in place from de­vel­oper Suc­cessEHS on day one.

“We’re not big enough to have our own IT per­son on staff, so we op­er­ate strictly on­line,” Thorn­ton says. “There are 29 FQHC or­ga­ni­za­tions in Louisiana, and well over half of us are on the same soft­ware. We can have user-group con­fer­ences and talk about our needs. As the data HRSA needs changes, we can im­ple­ment it to­gether.” The Health Re­sources and Ser­vices Ad­min­is­tra­tion re­quires clin­ics it funds to file re­ports on­line through its Uni­form Data Sys­tem on pa­tient de­mo­graph­ics, fi­nances and qual­ity mea­sures, which is much more dif­fi­cult to or­ga­nize with­out a boost from IT.

An EHR also helps the clinic gather data to im­prove pa­tient out­comes, Thorn­ton says. “With women’s health and di­a­betes, we can track all that and re­mind the providers what we need to be do­ing in the exam room it­self.” Lab re­sults, mean­while, “are in­ter­faced into the record so that providers can ac­cess it 24 hours a day over their cell­phones.”

The Winn clin­i­cal staff con­sists of a fam­ily prac­tice physi­cian, two nurse prac­ti­tion­ers, a physi­cian as­sis­tant and a den­tist. About 26% of Win­n­field’s fam­i­lies—three out of four with chil­dren un­der age 5—have in­comes at or be­low the poverty level. Not sur­pris­ingly, more than 83% of its pa­tients are ei­ther unin­sured or cov­ered by Med­i­caid, the Chil­dren’s Health In­sur­ance Pro­gram or other pub­lic as­sis­tance.

“We’ve ap­plied to put an ad­di­tional clinic in Grant Parish di­rectly to the south of us,” Thorn­ton says. Winn also re­ceived ap­proval to open a clinic in one of the schools, staffed with a nurse prac­ti­tioner and a be­hav­ioral spe­cial­ist. A bus takes stu­dents to the clinic’s den­tist, he says.

“When only 42% of our chil­dren are im­mu­nized in a timely man­ner and we have less than 10% who go to a den­tist be­fore age 5, we see the need,” Thorn­ton says.

Ru­ral health­care providers in Louisiana, in­clud­ing Bunkie Gen­eral Hos­pi­tal, a crit­i­cal-ac­cess fa­cil­ity, and a clinic in Win­n­field, are us­ing in­for­ma­tion tech­nol­ogy to im­prove pop­u­la­tion health.

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